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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELOINATION I hcrcby offrm under pcnelty of pcrjury thal I m cxempt from Ihc Contracto6' Licens llw for thc followinS Msn (Scc.7031.5 Busilcss and Pmfcssion Code): Any City or County which rcnuircs a lrcmit lo @nstrucl, altcr, imprcrc. ddmlish or rqrir my srwturc, prbr to ils issuec. also rcquircs thc alrplicant for such lrcmit to filc a signed slatemnt lhal he or shc is liccnsd punumt to thc Eovisions of the Conrractor's Licenrcd law (Chaptcr 9. Comrcing wilh Sâ‚¬lion 7000 of Division 3 of the Busiress od PrcfcssionsCodc)orthathcorshciscxctrlptthcrcfrcmordthcbasisforthcallcgcdcxctrrption. Anyviol.tionofSetionT03l.5bymy applicanl for I permit subjets thc applicmt lo I civil pcmlty of not mrc thil fivc hurdrcd dollrs ($50O). --1. as owncr of the propcny. or m), employecs with wagcs &s thcir solc compcnsalion. willdo lhc work and thc stnrcturc Ls rnt intenclcd or offercd for sale (Sec.7044, Busincss and Profcssions Coclc: Thc Contractor's Liccnse law docs nol apply to an owncr of thc propcrty who builds or improves thcrcon, arxl who docs such work himself or hersclf or through his or her own employecs, providcd that such imJrovcrnents are not intcndod or offcrcd for sah. lf. howcrcr. thc buihing or inprovcmcnt is sold within onc )rar of cornplction. the Owncr Buiklcr will have thc burden of proving that lrc or shc dkl not buih or improve thc property for thc puryxrsc of salc). _1. as owncr of thc proprty. am cxclusively contracting with licenscd conlractors to construct thc projrrt (Sec. 7(W, Busincss and Prrolbssion Codc: Thc Contractor's License Law does not apply to an owncr of progrcrty who builds or improves thcrc'on. and who contracts for such proicts with a Contraclor(s) liccnscd pursuant to the Contractor's Liccnsc taw). -lamexcmptunderSc.ction-.B'&P.C.forthisrcason.Dalc:( )rr lrt'r WORKERS' COMPM{SATION DECLARATION I hcrcby affirrn undcr pcnalty of grerjury one of the following dcrclarations: _l havc alxl will maintain a Ccrlificatc of Consent to Sclf-lnsurc for workers' compcnsalion, as povided for by Section 3700 of thc Latxrr Gdc. for thc perfonruncc of thc work for which thc pcrmit is issucd. _l havc and will maintain workcrs' compcnsation insurarrce. as rcquired by Scction 3700 of the [:bor Code. fbr thc performarrce of thc work for which ls conrpcnsation insurancc carricr arxl plicy number are: Carrier:- Policy -U .a L42ZL _l ccrtify that in thc pcrformancc of thc work for which this pcrmit is issued. I shall not enrploy any pcrson in any manner so as to bccomc subject to thc workers' compensation laws of California, and agrcc that if I should bcconrc subjcct to thc workers' conrpcnsation provisions of Scction 3700 of thc labor Code. I stull, forthwith comply with those provisions. WARNING: Failure to sccurc workcrs' compcnsation covcrage is unlawful, and shall subjcct an cmploycr to criminal pcnalties and civil fincs up lo one hundred thousand dollars ($100.0ffi), in to the cost of compcnsalion.as providcd for thc Scction of I-abor and attorncy's fccs. o LICENSED CON'TRACTOR DI'CLARAI'I()N I hcrcby aflinn undcr pcnalty of pcrjury that I arn licenscd undcr provision of Chaptcr 9 (comnrcncing with Scrction 7000) of Division 3 aof thc Busirrcss and hofessions Codc. and my liccnsc is in full force and effc.ct. orsLiccnsc a Nurnhcr: W I hcrcby nffim urdcr ]rcnalty of pcrjury tha thcrc is a onslruction hnding agcrcy for lhc pcrformcc of lhc work for which this lrcmil is issucd (SE. 3097. Civ. C.). [.cnder's Address: APPLICANT DECLARATION I horby affirm undcr pcnalty of prjury onc of thc following dcclarations: Dcmolition Pcrmits-Asbcstos Notification Fedcral Rcgulations (Titlc 40, Part6) -Rcqu ircd lettcr of Notification __l ccrtify that thc fedcralregulations rcgarding asbcstos rcnxlval ilre nol applicablc to this projcct. state that the atnvc infornution is corrcct. I agrce to conrply with all City and County arri hercby authorizc rcprcscntalives of this City and County to entcr thc abovc rrrcntioned property for inspcction Applicnnl or .\genl Permitee name (print):\-(- l.lcu zc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl ns u latio n I Roof Sheathinq ll'la"N t)fJa/&ffi6J Shear Wall Framinq lnsu latio n/En ergy Drywall Ext./lnt. Lath Brown Coat ltlasonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif rI ,, FINAL tt u 1^)Dt(lf, Gertificate of Occupancy Notes, Remarks, Etc. Ltl lo D/t+y / tl / -l,' Rev. 08-07-201 5